The Role of Interventional Radiology Techniques in the Management of Renal Angiomyolipomas

  • Ryan M. Kiefer
  • S. William StavropoulosEmail author
Minimally Invasive Surgery (T Guzzo, Section Editor)
Part of the following topical collections:
  1. Topical Collection on Minimally Invasive Surgery


Purpose of Review

Although benign, renal angiomyolipoma (AML) may lead to serious complications without appropriate management. The purpose of this review is to describe the role of and evidence for interventional radiology techniques in the management of patients with AML.

Recent Findings

For patients with renal masses and non-diagnostic imaging studies, image-guided percutaneous biopsy is found to be highly accurate and useful in directing patient management. Once the diagnosis of AML has been made based on either imaging or biopsy, arterial embolization of tumors that are symptomatic or >4 cm has been demonstrated to reduce the risk of hemorrhage as well as tumor size. Percutaneous ablation devices have been proposed as alternative strategies but remain investigational.


The utility of interventional radiology techniques including percutaneous core needle biopsy and prophylactic super-selective arterial embolization is safe and effective management strategies for patients presenting with AML tumors.


Angiomyolipoma Interventional radiology Arterial embolization Radiofrequency ablation Microwave ablation 


Compliance with Ethical Standards

Conflict of Interest

Ryan M. Kiefer declares no potential conflicts of interest.

S. William Stavropoulos reports personal fees from Bard and Cook and grants from Cook, B. Braun, and Sillajen.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.


Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. 1.
    Caliò A, Warfel KA, Eble JN. Pathological features and clinical associations of 58 small incidental angiomyolipomas of the kidney. Hum Pathol. 2016;58:41–6.CrossRefPubMedGoogle Scholar
  2. 2.
    Mues AC, Palacios JM, Haramis G, Casazza C, Badani K, Gupta M, et al. Contemporary experience in the management of angiomyolipoma. J Endourol. 2010;24(11):1883–6.CrossRefPubMedGoogle Scholar
  3. 3.
    Flum AS, Hamoui N, Said MA, Yang XJ, Casalino DD, McGuire BB, et al. An update on the diagnosis and management of renal angiomyolipoma. J Urol. 2016;195(April):834–46.CrossRefPubMedGoogle Scholar
  4. 4.
    Prasad TV, Singh A, Das CJ, Seth A. An unusually large renal angiomyolipoma peeping into the right atrium. BMJ Case Reports. 2016 Jun;27:2016.Google Scholar
  5. 5.
    Lane BR, Aydin H, Danforth TL, Zhou M, Remer EM, Novick AC, et al. Clinical correlates of renal angiomyolipoma subtypes in 209 patients: classic, fat poor, tuberous sclerosis associated and epithelioid. J Urol. 2008;180(3):836–43.CrossRefPubMedGoogle Scholar
  6. 6.
    Sooriakumaran P, Gibbs P, Coughlin G, Attard V, Elmslie F, Kingswood C, et al. Angiomyolipomata: challenges, solutions, and future prospects based on over 100 cases treated. BJU Int. 2009;105(1):101–6.CrossRefPubMedGoogle Scholar
  7. 7.
    Nelson CP, Sanda MG. Contemporary diagnosis and management of renal angiomyolipoma. J Urol. 2002;168(October):1315–25.CrossRefPubMedGoogle Scholar
  8. 8.
    Seyam RM, Bissada NK, Kattan SA, Mokhtar AA, Aslam M, Fahmy WE, et al. Changing trends in presentation, diagnosis and management of renal angiomyolipoma: comparison of sporadic and tuberous sclerosis complex-associated forms. Urology. 2008;72(5):1077–82.CrossRefPubMedGoogle Scholar
  9. 9.
    Davenport MS, Neville AM, Ellis JH, Cohan RH, Chaudhry HS, Leder RA. Diagnosis of renal angiomyolipoma with hounsfield unit thresholds: effect of size of region of interest and nephrographic phase imaging. Radiology. 2011;260(1):158–65.CrossRefPubMedGoogle Scholar
  10. 10.
    Song S, Park BK, Park JJ. New radiologic classification of renal angiomyolipomas. Eur J Radiol. 2016;85(10):1835–42.CrossRefPubMedGoogle Scholar
  11. 11.
    Schieda N, Hodgdon T, El-Khodary M, Flood TA, McInnes MDF. Unenhanced CT for the diagnosis of minimal-fat renal angiomyolipoma. AJR Am J Roentgenol. 2014;203(6):1236–41.CrossRefPubMedGoogle Scholar
  12. 12.
    Lee Y, Kim JK, Shim WH, Sung YS, Cho KS, Shin JH, et al. Does computer-aided diagnosis permit differentiation of angiomyolipoma without visible fat from renal cell carcinoma on MDCT? Am J Roentgenol. 2015;205(3):W305–12.CrossRefGoogle Scholar
  13. 13.
    Kim JK, Park S-Y, Shon J-H, Cho K-S. Angiomyolipoma with minimal fat: differentiation from renal cell carcinoma at biphasic helical CT. Radiology. 2004;230(3):677–84.CrossRefPubMedGoogle Scholar
  14. 14.
    Pierorazio PM, Patel HD, Johnson MH, Sozio SM, Sharma R, Iyoha E, et al. Distinguishing malignant and benign renal masses with composite models and nomograms: a systematic review and meta-analysis of clinically localized renal masses suspicious for malignancy. Cancer. 2016;122(21):3267–76.CrossRefPubMedGoogle Scholar
  15. 15.
    Sasiwimonphan K, Takahashi N, Leibovich BC, Carter RE, Atwell TD, Kawashima A. Differentiation of angiomyolipoma without visible fat from renal cell. Radiology. 2012;263(1):160–8.CrossRefPubMedGoogle Scholar
  16. 16.
    Schieda N, Kielar AZ, Al Dandan O, McInnes MDF, Flood TA. Ten uncommon and unusual variants of renal angiomyolipoma (AML): radiologic-pathologic correlation. Clin Radiol. 2015;70(2):206–20.CrossRefPubMedGoogle Scholar
  17. 17.
    Outwater EK, Blasbalg R, Siegelman ES, Vala M. Detection of lipid in abdominal tissues with opposed-phase gradient-echo images at 1.5 T: techniques and diagnostic importance. Radiographics. 1998;18(6):1465–80.CrossRefPubMedGoogle Scholar
  18. 18.
    Jinzaki M, Silverman SG, Akita H, Nagashima Y, Mikami S, Oya M. Renal angiomyolipoma: a radiological classification and update on recent developments in diagnosis and management. Abdom Imaging. 2014;39(3):588–604.CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Sun D, Wei C, Li Y, Lu Q, Zhang W, Hu B. Contrast-enhanced ultrasonography with quantitative analysis allows differentiation of renal tumor histotypes. Sci Rep. 2016;6(October):35081.CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Leão RRN, Richard PO, Jewett MAS. The role of biopsy for small renal masses. Int J Surg. 2016; In pressGoogle Scholar
  21. 21.
    Marconi L, Dabestani S, Lam TB, Hofmann F, Stewart F, Norrie J, et al. Systematic review and meta-analysis of diagnostic accuracy of percutaneous renal tumour biopsy. Eur Urol. 2016;69(4):660–73.CrossRefPubMedGoogle Scholar
  22. 22.
    • Jeon HG, Seo SI, Jeong BC, Jeon SS, Lee HM, Choi HY, et al. Percutaneous kidney biopsy for a small renal mass: a critical appraisal of results. J Urol. 2016;195(3):568–73. The authors in this study report a large, multicenter trial concluding that renal mass biopsies are safe and accurate in the diagnosis of unknown renal lesions.CrossRefPubMedGoogle Scholar
  23. 23.
    Rimon U, Duvdevani M, Garniek A, Golan G, Bensaid P, Ramon J, et al. Large renal angiomyolipomas: digital subtraction angiographic grading and presentation with bleeding. Clin Radiol. 2006;61(6):520–6.CrossRefPubMedGoogle Scholar
  24. 24.
    Oesterling JE, Fishman EK, Goldman SM, Marshall FF. The management of renal angiomyolipoma. J Urol. 1986 Jun;135(6):1121–4.PubMedGoogle Scholar
  25. 25.
    Yamakado K, Tanaka N, Nakagawa T, Kobayashi S, Yanagawa M, Takeda K. Renal angiomyolipoma: relationships between tumor size, aneurysm formation, and rupture. Radiology. 2002;225(1):78–82.CrossRefPubMedGoogle Scholar
  26. 26.
    Faddegon S, So A. Treatment of angiomyolipoma at a tertiary care centre: the decision between surgery and angioembolization. Can Urol Assoc J. 2011;5(6):E138–41.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Meyer A, Woldu SL, Weinberg AC, Thoreson GR, Pierorazio P, Matulay JT, et al. Predicting renal parenchymal loss after nephron sparing surgery. J Urol. 2015;194(3):658–63.CrossRefPubMedGoogle Scholar
  28. 28.
    Montag S, Rais-Bahrami S, Seideman CA, Rastinehad AR, Vira MA, Kavoussi LR, et al. Delayed haemorrhage after laparoscopic partial nephrectomy: frequency and angiographic findings. BJU Int. 2011;107(9):1460–6.CrossRefPubMedGoogle Scholar
  29. 29.
    Ghoneim TP, Thornton RH, Solomon SB, Adamy A, Favaretto RL, Russo P. Selective arterial embolization for pseudoaneurysms and arteriovenous fistula of renal artery branches following partial nephrectomy. J Urol. 2011;185(6):2061–5.CrossRefPubMedGoogle Scholar
  30. 30.
    Bissler J, Cappell K, Charles H, Song X, Liu Z, Prestifilippo J, et al. Rates of interventional procedures in patients with tuberous sclerosis complex-related renal angiomyolipoma. Curr Med Res Opin. 2015;31(8):1501–7.CrossRefPubMedGoogle Scholar
  31. 31.
    Bishay VL, Crino PB, Wein AJ, Malkowicz SB, Trerotola SO, Soulen MC, et al. Embolization of giant renal angiomyolipomas: technique and results. J Vasc Interv Radiol. 2010;21(1):67–72.CrossRefPubMedGoogle Scholar
  32. 32.
    Ginat DT, Saad WEA, Turba UC. Transcatheter renal artery embolization: clinical applications and techniques. Tech Vasc Interv Radiol. 2009;12(4):224–39.CrossRefPubMedGoogle Scholar
  33. 33.
    Patatas K, Robinson GJ, Ettles DF, Lakshminarayan R. Patterns of renal angiomyolipoma regression post embolisation on medium- to long-term follow-up. Br J Radiol. 2013;86(20120633)Google Scholar
  34. 34.
    Sauk S, Zuckerman DA. Renal artery embolization. Semin Intervent Radiol. 2011;28(4):396–406.CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Huang Q, Zhai R-Y. Embolization of symptomatic renal angiomyolipoma with a mixture of lipiodol and PVA, a mid-term result. Chin J Cancer Res. 2014;26(4):399–403.PubMedPubMedCentralGoogle Scholar
  36. 36.
    Chick CM, Tan BS, Cheng C, Taneja M, Lo R, Tan YH, et al. Long-term follow-up of the treatment of renal angiomyolipomas after selective arterial embolization with alcohol. BJU Int. 2010;105(3):390–4.CrossRefPubMedGoogle Scholar
  37. 37.
    Thulasidasan N, Sriskandakumar S, Ilyas S, Sabharwal T. Renal angiomyolipoma: mid- to long-term results following embolization with Onyx. Cardiovasc Intervent Radiol. 2016; doi: 10.1007/s00270-016-1432-0.PubMedGoogle Scholar
  38. 38.
    Villalta JD, Sorensen MD, Durack JC, Kerlan RK, Stoller ML. Selective arterial embolization of angiomyolipomas: a comparison of smaller and larger embolic agents. J Urol. 2011;186(3):921–7.CrossRefPubMedGoogle Scholar
  39. 39.
    Soulen MC, Faykus MH, Shlansky-Goldberg RD, Wein a J, Cope C. Elective embolization for prevention of hemorrhage from renal angiomyolipomas. J Vasc Interv Radiol. 1994;5(4):587–91.CrossRefPubMedGoogle Scholar
  40. 40.
    Planché O, Correas JM, Mader B, Joly D, Méjean A, Hélénon O. Prophylactic embolization of renal angiomyolipomas: evaluation of therapeutic response using CT 3D volume calculation and density histograms. J Vasc Interv Radiol. 2011;22(10):1388–95.CrossRefPubMedGoogle Scholar
  41. 41.
    Ramon J, Rimon U, Garniek A, Golan G, Bensaid P, Kitrey ND, et al. Renal angiomyolipoma: long-term results following selective arterial embolization. Eur Urol. 2009;55(5):1155–62.CrossRefPubMedGoogle Scholar
  42. 42.
    Incedayi M, Turba UC, Arslan B, Sabri SS, Saad WEA, Matsumoto AH, et al. Endovascular therapy for patients with renal angiomyolipoma presenting with retroperitoneal haemorrhage. Eur J Vasc Endovasc Surg. 2010;39(6):739–44.CrossRefPubMedGoogle Scholar
  43. 43.
    Chan CK, Yu S, Yip S, Lee P. The efficacy, safety and durability of selective renal arterial embolization in treating symptomatic and asymptomatic renal angiomyolipoma. Urology. 2011;77(3):642–8.CrossRefPubMedGoogle Scholar
  44. 44.
    Chang Y-H, Wang L-J, Chuang C-K, Wong Y-C, Wu C-T, Hsieh M-L. The efficacy and outcomes of urgent superselective transcatheter arterial embolization of patients with ruptured renal angiomyolipomas. J Trauma. 2007;62(6):1487–90.CrossRefPubMedGoogle Scholar
  45. 45.
    Murray TE, Doyle F, Lee M. Transarterial embolization of angiomyolipoma: a systematic review. J Urol. 2015;194(3):635–9.CrossRefPubMedGoogle Scholar
  46. 46.
    Lee SY, Hsu HH, Chen YC, Huang CC, Wong YC, Wang LJ, et al. Embolization of renal angiomyolipomas: short-term and long-term outcomes, complications, and tumor shrinkage. Cardiovasc Intervent Radiol. 2009;32(6):1171–8.CrossRefPubMedGoogle Scholar
  47. 47.
    •• Hocquelet A, Cornelis F, Le Bras Y, Meyer M, Tricaud E, Lasserre AS, et al. Long-term results of preventive embolization of renal angiomyolipomas: evaluation of predictive factors of volume decrease. Eur Radiol. 2014;24(8):1785–93. These authors show that prophylactic embolization is a safe procedure with high success rates at preventing hemorrhage and causing tumor shrinkage over long-term follow-up.CrossRefPubMedGoogle Scholar
  48. 48.
    Chatziioannou A, Gargas D, Malagari K, Kornezos I, Ioannidis I, Primetis E, et al. Transcatheter arterial embolization as therapy of renal angiomyolipomas: the evolution in 15 years of experience. Eur J Radiol. 2012;81(9):2308–12.CrossRefPubMedGoogle Scholar
  49. 49.
    Lee SY, Hsu HH, Chen YC, Huang CC, Wong YC, Wang LJ. Evaluation of renal function of angiomyolipoma patients after selective transcatheter arterial embolization. Am J Med Sci. 2009;337(2):103–8.CrossRefPubMedGoogle Scholar
  50. 50.
    Lenton J, Kessel D, Watkinson AF. Embolization of renal angiomyolipoma: immediate complications and long-term outcomes. Clin Radiol. 2008;63(8):864–70.CrossRefPubMedGoogle Scholar
  51. 51.
    Rimon U, Duvdevani M, Garniek A, Golan G, Bensaid P, Ramon J, et al. Ethanol and polyvinyl alcohol mixture for transcatheter embolization of renal angiomyolipoma. Am J Roentgenol. 2006;187(3):762–8.CrossRefGoogle Scholar
  52. 52.
    Sheth RA, Feldman AS, Walker TG. Renoduodenal fistula after transcatheter embolization of renal angiomyolipoma. Cardiovasc Intervent Radiol. 2015;38(1):232–5.CrossRefPubMedGoogle Scholar
  53. 53.
    Warncke JC, Brodie KE, Grantham EC, Catarinicchia SP, Tong S, Kondo KL, et al. Pediatric renal angiomyolipomas in tuberous sclerosis complex. J Urol. 2016; doi: 10.1016/j.juro.2016.09.082.PubMedGoogle Scholar
  54. 54.
    Boorjian SA, Sheinin Y, Crispen PL, Lohse CM, Kwon ED, Leibovich BC. Hormone receptor expression in renal angiomyolipoma: clinicopathologic correlation. Urology. 2008;72(4):927–32.CrossRefPubMedPubMedCentralGoogle Scholar
  55. 55.
    Preece P, Mees B, Norris B, Christie M, Wagner T, Dundee P. Surgical management of haemorrhaging renal angiomyolipoma in pregnancy. Int J Surg Case Rep. 2015;7:89–92.CrossRefPubMedCentralGoogle Scholar
  56. 56.
    Myoen S, Mitsuzuka K, Saito H, Ota H, Takase K, Arai Y. Spontaneous rupture of a renal angiomyolipoma at 25 weeks of pregnancy treated with transarterial embolization: a case report and review of the literature. Int J Urol. 2015;22(7):710–2.CrossRefPubMedGoogle Scholar
  57. 57.
    Kira S, Sawada N, Miyamoto T, Mitsui T, Zakoji H, Takeda M. Hemorrhagic renal angiomyolipoma in pregnancy effectively managed by immediate cesarean section and elective transcatheter arterial embolization: a case report. J Endourol Case Reports. 2016;2(1):65–7.CrossRefGoogle Scholar
  58. 58.
    Venkatesan AM, Wood BJ, Gervais DA. Percutaneous ablation in the kidney. Radiology. 2011;261(2):375–91.CrossRefPubMedPubMedCentralGoogle Scholar
  59. 59.
    Castle SM, Gorbatiy V, Ekwenna O, Young E, Leveillee RJ. Radiofrequency ablation (RFA) therapy for renal angiomyolipoma (AML): an alternative to angio-embolization and nephron-sparing surgery. BJU Int. 2012;109(3):384–7.CrossRefPubMedGoogle Scholar
  60. 60.
    Tan YK, Best SL, Olweny E, Park S, Trimmer C, Cadeddu JA. Radiofrequency ablation of incidental benign small renal mass: outcomes and follow-up protocol. Urology. 2012;79(4):827–30.CrossRefPubMedGoogle Scholar
  61. 61.
    Zhi-yu H, Ping L, Xiao-ling Y, Zhi-gang C, Fang-yi L, Jie Y. Ultrasound-guided percutaneous microwave ablation of sporadic renal angiomyolipoma: preliminary results. Acta Radiol. 2015;56(1):56–62.CrossRefGoogle Scholar
  62. 62.
    Martin J, Athreya S. Meta-analysis of cryoablation versus microwave ablation for small renal masses: is there a difference in outcome? Diagn Interv Radiol. 2013;19(6):501–7.PubMedGoogle Scholar
  63. 63.
    Byrd GF, Lawatsch EJ, Mesrobian HG, Begun F, Langenstroer P. Laparoscopic cryoablation of renal angiomyolipoma. J Urol. 2006;176(4):1512–6.CrossRefPubMedGoogle Scholar
  64. 64.
    Caviezel A, Terraz S, Schmidlin F, Becker C, Iselin CE. Percutaneous cryoablation of small kidney tumours under magnetic resonance imaging guidance: medium-term follow-up. Scand J Urol Nephrol. 2008;42(5):412–6.CrossRefPubMedGoogle Scholar
  65. 65.
    Kuusk T, Biancari F, Lane B, Tobert C, Campbell S, Rimon U, et al. Treatment of renal angiomyolipoma: pooled analysis of individual patient data Endourology and technology. BMC Urol. 2015; 15(123): doi:  10.1186/s12894-015-0118-2.
  66. 66.
    Johnson SC, Graham S, D’Agostino H, Elmajian DA, Shingleton WB. Percutaneous renal cryoablation of angiomyolipomas in patients with solitary kidneys. Urology. 2009;74(6):1246–9.CrossRefPubMedGoogle Scholar
  67. 67.
    Krueger DA, Northrup H, Northrup H, Krueger DA, Roberds S, Smith K, et al. Tuberous sclerosis complex surveillance and management: recommendations of the 2012 International Tuberous Sclerosis Complex Consensus Conference. Pediatr Neurol. 2013;49(4):255–65.CrossRefPubMedPubMedCentralGoogle Scholar
  68. 68.
    Patel HD, Riffon MF, Joice GA, Johnson MH, Chang P, Wagner AA, et al. A prospective, comparative study of quality of life among patients with small renal masses choosing active surveillance and primary intervention. J Urol. 2016;196(5):1356–62.CrossRefPubMedGoogle Scholar
  69. 69.
    Ouzaid I, Autorino R, Fatica R, Herts BR, McLennan G, Remer EM, et al. Active surveillance for renal angiomyolipoma: outcomes and factors predictive of delayed intervention. BJU Int. 2014;114(3):412–7.PubMedGoogle Scholar
  70. 70.
    Kothary N, Soulen MC, Clark TWI, Wein AJ, Shlansky-Goldberg RD, Crino PB, et al. Renal angiomyolipoma: long-term results after arterial embolization. J Vasc Interv Radiol. 2005;16:45–50.CrossRefPubMedGoogle Scholar
  71. 71.
    Sheth RA, Feldman AS, Paul E, Thiele EA, Walker TG. Sporadic versus tuberous sclerosis complex-associated angiomyolipomas: predictors for long-term outcomes following transcatheter embolization. J Vasc Interv Radiol. 2016;27(10):1542–9.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2017

Authors and Affiliations

  1. 1.Department of Radiology, Division of Interventional RadiologyHospital of University of Pennsylvania Medical CenterPhiladelphiaUSA

Personalised recommendations